Naoki Kotani, Tetsuya Kushikata, et al
Intrathecal methylprednisolone for intractable postherpetic neuralgia
New Eng J Med. 343Nov.23, 2000, 1514-1519
There is no effective treatment for postherpetic neuralgia. As there is evidence that there is an inflammatory component in this disorder, the authors have assessed treatment with intrathecally. administered methylprednisolone to reduce pain.
A New Treatment for Postherpetic Neuralgia
Randomized controlled trials have supported the use of older antidepressants – such as amitryptyline, nortryptiline, but nearly 50% patients either do not respond or have intolerable adverse effects. Recent trials of methylprednisolone + lidocaine have supported the use of the anticonvulsant - gabapentin, (fewer side effects), opioid oxycodone and a lidocaine skin patch.
Currently, lidocaine skin patch may be used at the start, if no relief, use nortryptyline (fewer side effects) at a low dose of 10-20 mg/day, with gradual increase in dosage. Alternatively, gabapentin may be used starting with a low dose and upto a maximum of 3500mg/day. Opioids can be used in refractory cases.
However, none of these approaches are fully satisfactory. In the study by Kotani et al during the 2 yrs of trial no critical adverse effects, such as arachnoiditis or neurotoxic effects from methylprednisolone were noted. However, use of this technique in larger number of patients and observation during longer follow up periods will be needed to identify potentially severe adverse effects. This study does not address the problem of postherpetic neuralgia involving the trigeminal nerve.